Comparative anatomy of cutaneous muscles of the face

Comparative anatomical studies of monkeys, apes, and humans have clarified essential factors involved in the structure of the cutaneous muscles of the face. Among the findings are that the platysma muscle is a very important entity because it is the only muscle without any bony attachments. In addition, the platysma is a fan-shaped structure that has been divided artificially by classical anatomists into five elements. The parotid fascia forms part of this fan-shaped fibromuscular structure and is not of the deep fascia. As such, these findings require a revision of the classical anatomical concepts of the parotid space.     

Subfascial lifting

The authors demonstrate by anatomical dissection that inaccuracies made by classical anatomists have worried plastic surgeons for many years. They demonstrate that continuity between the parotid fascia and the fibrous platysma has not been recognized. In addition, anatomists in the past have not been aware that the platysma is a unique type of fasciomuscular layer because in contrast to conventional anatomical opinions, the platysma has no bony attachment to the mandible.     

Subfascial lifting

The authors demonstrate by anatomical dissection that inaccuracies made by classical anatomists have worried plastic surgeons for many years. They demonstrate that continuity between the parotid fascia and the fibrous platysma has not been recognized. In addition, anatomists in the past have not been aware that the platysma is a unique type of fasciomuscular layer because in contrast to conventional anatomical opinions, the platysma has no bony attachment to the mandible.     

Skin and Platysma Muscle Anchoring

Anatomically, the platysma muscle is composed of two parts: a facial part and a cervical part. This observation allows a better understanding of the modifications due to aging. The correction of platysma bands needs nearly vertical directional vectors at the facial level. The periosteum of the malar bone and the anterior border of the parotid fascia are two solid structures that are not modified during aging. They allow the anchoring of the ptotic tissues including premalar fat pads, jowls, and platysma bands. The connections between the skin and the platysma muscle are not affected, although most of the described techniques need a detachment of the platysma muscle from the skin and a suture of the anterior border via a submental approach. Furthermore, the posterior border of the platysma muscle is not modified by aging. This explains why it is useless to detach this structure. The principles of the proposed technique are fundamentally different. Lore's fascia is used as a guide for approaching the trunk of the facial nerve. Labbé and colleagues have done an anatomic study of this procedure. It allows a solid anchoring of the platysma muscle, which is not detached from the skin. This is the key to the operation because the skin and the muscle are elevated en bloc. The author demonstrates that the absence of separation between skin and muscle, particularly at the cervical level, is a very efficient means for correcting platysma bands and for obtaining good definition of the cervicomental angle.     

Less invasive face-lifting: platysma anchoring techniques

An analysis of anatomic changes during aging of the face and neck has led to fundamental changes in surgical technique. As a result, the cutaneoplatysmal complex and submuscular aponeurotic system are now anchored to fixed and solid structures: the malar periosteum, parotid fascia, and prelobar fibrous tissue. This technique, which is called skin and platysma muscle anchoring, limits cervical cutaneous undermining and avoids a submental approach. A repositioning of the anatomic elements in their initial sites explains the natural aspect of the results.     

Variability of the postauricular muscle complex: analysis of 40 hemicadaver dissections

BACKGROUND: The postauricular area is often explored by reconstructive and otologic surgeons. We previously reported on the use of postauricular tissues as a graft for wrapping hydroxyapatite implants in orbital reconstruction. This procedure reduced the incidence of implant exposure, while achieving acceptable cosmetic results. Although much is known about the postauricular area, muscle and fascial relationships and potential variations in anatomy remain ill defined. OBJECTIVES: To identify and analyze variations in the patterns of the postauricular muscle complex (PMC) and to study the relationships of the fascial contributions from the components that make up the PMC. METHODS: Dissections were performed using 40 fresh specimens. Muscular and fascial components of the PMC were dissected, analyzed, and photographed. RESULTS: The PMC receives contributions from the occipitalis and trapezius muscles, the deep temporal and sternocleidomastoid fasciae, and the superior and posterior auricular and platysma muscles. Major contributors to the PMC were present in every specimen. Minor contributors were more variable in their presence and contributions. The posterior auricular muscle was identified as having several muscle bundles in 1 specimen and absent in 2 specimens (5%). The occipitalis fascia was seen to insert superior to the auricle and to blend with the deep temporal fascia in 3 cases (7%). The platysma muscle contributed to the PMC in 8 cases (20%). CONCLUSIONS: This study demonstrated important variations in the presence and contributions of 7 previously known muscular structures and their role in forming the PMC. Seven distinct patterns are identified, and the potential clinical implications of these anatomical variations are illustrated.     

Five-Year Experience with Modified Fogli (Loré’s Fascia Fixation) Platysmaplasty

Over a 5-year period, my technique of approaching and modifying the aging neck has changed from direct suturing of the medial platysma bands and strong posterior traction of the platysma to superior elevation of the posterior platysma and strong fixation to the tympanoparotid fascia. When indicated, redundant anterior platysmal bands are resected instead of approximated. Evaluation of these anterior bands preoperatively for thickness and degree of descent allows more precise decision-making regarding the need to resect redundant and excessively thick or long anterior platysmal bands. The added advantage of the strong fixation of the platysma in a vertical fashion to Loré’s fascia (the tympanoparotid fascia) leads not only to an improvement in the contour of the jawline and submental area but also to the undervalued aesthetic feature of a defined contour and visually increased length of the sternomastoid muscle.     

改良SMAS分离悬吊面中部除皱术

为了提高面中部除皱手术疗效和减少手术创伤,根据耳前部SMAS相对与下方组织紧密相连的解剖特点,将SMAS分为固定的和移动的两部分,提出于剥离移动SMAS后悬吊于固定的SMAS上的改良SMAS分离悬吊面中部除皱方法,以减少手术并发症。自1995年1至11月经斯德拉斯堡欧洲美容整形诊所31例的实践,均取得满意疗效。认为,移动的SMAS是应用SMAS悬吊除皱术的关键组织结构,固定的SMAS是手术设计必要的组织基础。     

Does the investing layer of the deep cervical fascia exist?

BACKGROUND: The placement of the superficial cervical plexus block has been the subject of controversy. Although the investing cervical fascia has been considered as an impenetrable barrier, clinically, the placement of the block deep or superficial to the fascia provides the same effective anesthesia. The underlying mechanism is unclear. The aim of this study was to investigate the three-dimensional organization of connective tissues in the anterior region of the neck. METHODS: Using a combination of dissection, E12 sheet plastination, and confocal microscopy, fascial structures in the anterior cervical triangle were examined in 10 adult human cadavers. RESULTS: In the upper cervical region, the fascia of strap muscles in the middle and the fasciae of the submandibular glands on both sides formed a dumbbell-like fascia sheet that had free lateral margins and did not continue with the sternocleidomastoid fascia. In the lower cervical region, no single connective tissue sheet extended directly between the sternocleidomastoid muscles. The fascial structure deep to platysma in the anterior cervical triangle comprised the strap fascia. CONCLUSIONS: This study provides anatomical evidence to indicate that the so-called investing cervical fascia does not exist in the anterior triangle of the neck. Taking the previous reports together, the authors' findings strongly suggest that deep potential spaces in the neck are directly continuous with the subcutaneous tissue.     

Use of deep planes in surgery of rejuvenation of the face

Since 1976, anatomical studies intensively performed in France have demonstrated the surgical interest in using the superficial musculo-aponevrotic system in the face, and also a subperiosteal malar approach. The SMAS is mostly a surgical structure. It could be considered as a remnant of a primitive subcutaneous muscle which would have been located in the superficialis fascia; its stays outward the parotid gland. Muscular fibers have been found inside, uniting from-down the patysma muscle toward the periphery of the frontalis muscle at the top. Risorius muscle is included in this structure. Its surgical interest is that it allows to relieve skin tension during a face lift by a fibromuscular associated stretch. The modern way in face lifting should prevent the fixed appearance of a too tight skin-pull, when skin is redraped alone. Risks of facial nerve injury are minimal when the proper technique is used. It is possible, in the same way, during a blepharoplasty to stretch the orbicularis oculi muscle, like the muscular resuturing of an inguinal hernia repair. Each of this technique has its own different indications now well defined. The authors shows this experience after 150 cases of face lift operations and makes an analysis of the advantages and draw backs of using the SMAS in cases of rejuvenating face operations.     

浅表肌腱膜系统多重悬吊的全颜面除皱术

目的探索一种操作简单、安全、效果持久的全颜面除皱术式，以利于推广应用。方法采用浅表肌腱膜系统(superficial musclo-aponeurotic system，SMAS)多重悬吊法进行全颜面除皱术，首先进行广泛皮下组织分离；接着应用1号丝线折叠缝合切口前1～2cm的SMAS，缝合间距1cm，折叠量约1～2cm，将颈阔肌后缘略做分离，向后上与胸锁乳突肌筋膜缝合；再用4-0可吸收线将眼轮匝肌及口角、鼻翼附近的SMAS分区向外上悬吊缝合。结果两年来临床应用此法为48例进行手术，术后随访6～16个月，无面神经损伤、血肿等严重并发症，受术者对手术效果均满意。并发症包括：颞部秃发3例，暂时性不对称2例，耳后瘢痕增生2例。结论本法克服了单纯皮下分离除皱时疗效不持久的缺点，避免分离SMAS造成的面神经损伤。实践证明，SMAS多重悬吊的全颜面除皱术是一种操作简单、安全、效果持久的除皱术式。     

Submental region in young adults]

Techniques of correction of thickening of the submental region are based on an anatomical analysis: position of the hyoid bone, mental protrusion, supra- or sub-platysmal steatomery, anatomy of the platysma muscle. Defatting procedures can be performed with an aspiration cannula, but a musculoplasty is sometimes required. Only direct exploration allows modelling of the fat situated between the platysma and the floor of the mouth.     

The value of anatomical study of the platysma muscle in cervical lifting

Medial fibers of the platysma muscle present anatomical variations at the submental area. It is important that patients be operated on according to the anatomical distribution of these fibers. The method described is easy and safe, based on anatomical studies and on clinical observations. It is another option for the treatment of cervicofacial deformities.Presented at the VIIIth International Congress of Plastic and Reconstructive Surgery, Montreal, June–July, 1983     

Cervical lift: Surgical correction of fat contour problems combined with full-width platysma muscle flaps

Correction of neck deformities due to fat, platysma muscle bands, or a combination of these deformities along with sagging of all neck tissue can be satisfactorily corrected by surgery. A knowledge of the anatomy of the face and neck is necessary in order to make an accurate diagnosis of the anatomical causes and to execute appropriate and safe surgical correction. A combination of thorough fat removal and full-width platysma muscle flaps converted into deep-layer sling support can eliminate the objectionable neck features, prevent recurring vertical muscle bands, produce pleasing neck contours along with a definition of the mandibular border, and avoid the problems which frequently occur when techniques which rely on skin tension or skin traction alone are used.     

Face lift, part 5: suspending sutures for platysma cording

We describe the technical details used in applying nonabsorbable sutures running from the anterior platysma muscles and/or adjacent fascia back to the fascia just in front of or covering the sternocleidomastoid muscles. These sutures usually pass 1.5-2 cm below the angle of the mandible. Anteriorly, they cover or are attached to the platysma muscles at the level of the cervical concavity or angle. The sutures suspend or draw back the superficial musculoaponeurotic system (SMAS) at this level, preventing some of the anterior displacement of the platysma when it is contracted in normal use. We believe that the sutures have relatively long-lasting effects and that they delay the early return of "platysma cording" after cheek-neck lifting. Their application using Reverdin and Keith needles is demonstrated. Differences in technique when submental lipectomy is and is not performed with the lift are shown.     

针刺手三里穴位动态超声显像

目的动态观察手三里穴位在针刺条件下的超声影像学解剖特征。方法选取健康志愿者15名,采用高频超声观察针灸针刺入受试者双侧手臂手三里穴后针尖的位置,以及针刺过程中与得气相关的解剖学结构。结果针刺15名受试者双侧手三里穴共30个穴位点均得气,针尖位置:桡侧腕伸肌13个,桡侧腕伸肌与旋后肌间筋膜9个,旋后肌浅层2个,旋后肌内筋膜4个,旋后肌深层1个,桡骨表面1个。28个(28/30,93.33%)针尖位于筋膜旁及筋膜集中处获得较强得气感、2个(2/30,6.67%)针尖位于较浅层即可获得较强得气感。高频超声可以清楚显示针尖点附近筋膜内的细小神经,二维声像图表现:桡神经深支沿着筋膜发出许多细小的分支,横断面声像图上呈筛孔样、回声较周围筋膜组织稍低。结论高频超声可以实时、动态、清楚地显示针刺点附近筋膜及筋膜内的细小神经分布,并可对针灸位置进行定量测定。     

Lateral congenital anomalies of the pharyngeal apparatus: part III. cadaveric representation of the course of second and third cleft and pouch fistulas

"Stepladder" surgery for fistula from second or third pharyngeal cleft and pouch is "blind." Neither intraoperative methylene blue injection and probing nor preoperative imaging (fistulogram ultrasound, computed tomography, magnetic resonance imaging) reveal three-dimensional anatomic relations of fistulas. This article describes the most common second and third fistula courses and demonstrates representation of their tracts with wires in human cadavers. A second cleft and pouch fistula, at its external opening, pierces superficial cervical fascia (and platysma), then investing cervical fascia, and travels under the sternocleidomastoid muscle, superficial to the sternohyoid and anterior belly of omohyoid. It ascends along the carotid sheath, and at the upper border of the thyroid cartilage it pierces the pretracheal fascia. Characteristically, it courses between the carotid bifurcation and over the hypoglossal nerve. After passing beneath the posterior belly of the digastric muscle and the stylohyoid, it hooks around both glossopharyngeal nerve and stylopharyngeus muscle. The fistula reaches the pharynx below the superior constrictor muscle. The course of a third cleft and pouch fistula is similar until it has pierced pretracheal fascia; then it passes over the hypoglossal nerve and behind the internal carotid, finally descending parallel to the superior laryngeal nerve, reaching the thyrohyoid membrane cranial to the nerve.     

Controversias en la anatomía quirúrgica prostática. Revisión de la literarura

IntroductionRadical prostatectomy technique has improved in the last years based on accumulated surgical experience and new anatomical findings. We think it is time to update anatomical concepts to standardized the criteria for mentioning structures related with radical prostatectomyMaterial and MethodWith the followings key words: “cavernosal nerves, prostatectomy, anatomy, neurovascular bundle” we search in Medline/PubMed database selecting papers fulfilling the search criteria.ConclusionsThe prostate does not have a true capsule but rather an incomplete fibromuscular band as an intrinsic part of the gland. Periprostatic fascia seems to be a different structure from this fibromuscular band. Histologically Denonvilliers´s fascia is formed by two thin layers that cannot be separated during surgery. The longitudinal smooth muscle fibres located beneath the posterior bladder neck corresponds to the posterior longitudinal fascia of the detrusor muscle. Cavernosal nerves are located between the two layers of the endopelvic fascia, the inner layer could be named periprostatic fascia and the outer, levator ani fascia. Cavernosal nerves merged from the pelvic plexus running within a neurovascular bundle around the prostate that could be found as a singular bundle or spread all around the anterolateral surface of this gland. There are overlapping terms to designate the pelvic fascia, therefore it could be useful for Urologists to standardized them.     

Anatomical Variations Analysis of the External Jugular Vein,Great Auricular Nerve,and Posterosuperior Border of the Platysma Muscle

This article describes the observations collected from the dissection of 10 nonformalinized cadavers analyzed in respect to the anatomical relation variations between the external jugular vein, the great auricular nerve, and the posterosuperior border of the platysma muscle.     

Superficial fascia rhytidectomy. A restoration of the SMAS with control of the cervicomental angle

The surgical correction of an anatomic defect should re-establish the normal relationship of the tissues which contribute to the defect and restore or improve function. When the repair of the anatomic defect is not maintained, it may be necessary to alter the tissues to accomplish a more lasting result. Restoration of the SMAS cephalad to the cervicomental angle by superficial fascia rhytidectomy with a complete transverse resection of a segment of the platysma muscle at the level of the cervicomental angle fulfills the criteria of the young face by improving the function and contours of the face (changes that are characteristic of aging).